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psnet.ahrq.gov/node/60339/psn-pdf
May 20, 2020 - We Want to Know-a mixed methods evaluation of a
comprehensive program designed to detect and address
patient-reported breakdowns in care.
May 20, 2020
Fisher KA, Smith KM, Gallagher TH, et al. We Want to Know-a mixed methods evaluation of a
comprehensive program designed to detect and address patient-reported brea…
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psnet.ahrq.gov/node/40038/psn-pdf
December 23, 2016 - A follow-up report on preventing suicide: focus on
medical/surgical units and the emergency department.
December 23, 2016
A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department.
Sentinel Event Alert. 2010;46(46):1-4.
https://psnet.ahrq.gov/issue/follow-report-prevent…
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psnet.ahrq.gov/node/37729/psn-pdf
June 12, 2008 - Introduction of medical emergency teams in Australia and
New Zealand: a multi-centre study.
June 12, 2008
Jones D, George C, Hart GK, et al. Introduction of medical emergency teams in Australia and New
Zealand: a multi-centre study. Crit Care. 2008;12(2):R46. doi:10.1186/cc6857.
https://psnet.ahrq.gov/issue/introd…
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psnet.ahrq.gov/node/39777/psn-pdf
November 04, 2012 - The Economic Measurement of Medical Errors.
November 4, 2012
Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of
Actuaries; 2010.
https://psnet.ahrq.gov/issue/economic-measurement-medical-errors
Although the Institute of Medicine's estimate of up to 98,000 deaths ye…
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psnet.ahrq.gov/node/37096/psn-pdf
June 24, 2010 - Impact of diagnosis-timing indicators on measures of
safety, comorbidity, and case mix groupings from
administrative data sources.
June 24, 2010
Naessens JM, Campbell CR, Berg B, et al. Impact of diagnosis-timing indicators on measures of safety,
comorbidity, and case mix groupings from administrative data sources…
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psnet.ahrq.gov/node/41317/psn-pdf
January 31, 2013 - Variation in 17 obstetric care pathways: potential danger
for health professionals and patient safety?
January 31, 2013
Sarrechia M, Van Gerven E, Hermans L, et al. Variation in 17 obstetric care pathways: potential danger for
health professionals and patient safety? J Adv Nurs. 2013;69(2):278-85. doi:10.1111/j.136…
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psnet.ahrq.gov/node/37514/psn-pdf
February 04, 2015 - Who pays for medical errors? An analysis of adverse
event costs, the medical liability system, and incentives
for patient safety improvement.
February 4, 2015
Mello MM, Studdert DM, Thomas EJ, et al. Who Pays for Medical Errors? An Analysis of Adverse Event
Costs, the Medical Liability System, and Incentives for P…
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psnet.ahrq.gov/node/36184/psn-pdf
June 13, 2011 - Developing and implementing new safe practices:
voluntary adoption through statewide collaboratives.
June 13, 2011
Leape L, Rogers G, Hanna D, et al. Developing and implementing new safe practices: voluntary adoption
through statewide collaboratives. Qual Saf Health Care. 2006;15(4):289-95.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/43771/psn-pdf
May 01, 2015 - The Public's Views on Medical Error in Massachusetts.
May 1, 2015
Boston, MA: Harvard School of Public Health; December 2014.
https://psnet.ahrq.gov/issue/publics-views-medical-error-massachusetts
This statewide public telephone survey in Massachusetts found that more than 20% of respondents
experienced a medical …
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psnet.ahrq.gov/node/39368/psn-pdf
May 04, 2010 - Results of the Medications At Transitions and Clinical
Handoffs (MATCH) study: an analysis of medication
reconciliation errors and risk factors at hospital
admission.
May 4, 2010
Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications At Transitions and Clinical
Handoffs (MATCH) Study: An Analysis…
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psnet.ahrq.gov/node/41806/psn-pdf
October 31, 2012 - Computer viruses are "rampant" on medical devices in
hospitals.
October 31, 2012
Talbot D. MIT Technology Review. October 17, 2012.
https://psnet.ahrq.gov/issue/computer-viruses-are-rampant-medical-devices-hospitals
This article highlights risks associated with malicious software on medical equipment and how it ca…
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psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement
July 17, 2024 - July 17, 2024
Preventable Hospitalizations: A Window Into Primary and Preventive Care
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psnet.ahrq.gov/issue/measure-dx-resource-identify-analyze-and-learn-diagnostic-safety-events
August 01, 2012 - October 23, 2019
Preventable Hospitalizations: A Window Into Primary and Preventive Care
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psnet.ahrq.gov/node/33676/psn-pdf
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann
Arbor VA …
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psnet.ahrq.gov/node/37372/psn-pdf
August 06, 2008 - Hospitals look to improve informed consent process.
August 6, 2008
O'Reilly KB.
https://psnet.ahrq.gov/issue/hospitals-look-improve-informed-consent-process
This article discusses the impact of health literacy on patient care and describes initiatives to improve
patients' comprehension of informed consent for proc…
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psnet.ahrq.gov/node/39734/psn-pdf
November 14, 2011 - Man falls off surgical table; St. Joseph's Hospital sued.
November 14, 2011
Smith ML; Wolfe WA.
https://psnet.ahrq.gov/issue/man-falls-surgical-table-st-josephs-hospital-sued
This newspaper article reports on a lawsuit regarding a safety incident that led to injury and subsequent
death of a patient.
https://psnet…
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psnet.ahrq.gov/node/39507/psn-pdf
April 28, 2010 - Hospital infections hard to gauge.
April 28, 2010
https://psnet.ahrq.gov/issue/hospital-infections-hard-gauge
This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated
infections in Pennsylvania.
https://psnet.ahrq.gov/issue/hospital-infections-hard-gauge
https:/…
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psnet.ahrq.gov/node/36298/psn-pdf
September 27, 2006 - Hospital Reporting of Deaths Related to Restraint and
Seclusion.
September 27, 2006
Levinson DR. Washington DC: Office of the Inspector General; September 2006. OEI-09-04-00350
https://psnet.ahrq.gov/issue/hospital-reporting-deaths-related-restraint-and-seclusion
This report presents findings from an investigatio…
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psnet.ahrq.gov/node/40303/psn-pdf
May 16, 2019 - Safer Hospital Care: Strategies for Continuous
Innovation, Second Edition.
May 16, 2019
Raheja D. New York, NY: Productivity Press; 2019. ISBN: 9780367178482
https://psnet.ahrq.gov/issue/safer-hospital-care-strategies-continuous-innovation
This publication provides various strategies to drive innovation in patient…
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psnet.ahrq.gov/node/34123/psn-pdf
November 02, 2014 - Preventing Infections in the Hospital—What You As a
Patient Can Do.
November 2, 2014
National Patient Safety Foundation; NPSF
https://psnet.ahrq.gov/issue/preventing-infections-hospital-what-you-patient-can-do
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines…